CME Activity Form

Thank you for your interest in presenting an educational activity. Please complete the following form and submit. Contact Caitlyn Boyd, Senior Manager of Medical Staff Division with questions (cboyd@tstelemed.com).

Part One: Disclosures, Planning and Abstract

Disclosures

You will receive an email from our joint provider, Peerpoint to sign off this portion of the activity form. Please select only ONE. *

*Ineligible company, as defined by the ACCME: "any entity whose primary business is producing, marketing, re-selling, or distributing healthcare products used by or on patients."

This activity will NOT receive financial and/or educational grant support from an ineligible company as defined by the ACCME*.

This activity will or may receive financial and/or educational grant support from an ineligible company as defined by the ACCME*.

List the grant companies and dollar amount of each grant *

Planning

Name(s) and Email(s) of Presenter(s) *

Disclosure forms will be emailed to all presenters

Working Title *

Hours of presentation / instruction *

Please list in increments of 15 minutes (0.25 hours).

Type of Activity *

Select all that apply

Webinar

Live

Enduring (recorded to watch at a later date)

Rationale for Webinar *

Select all that apply

Provides opportunity for real-time participant interaction

Increases opportunities for learning directly from expert presenters

Setting facilitates discussion of activity

Other

Rationale for Webinar Other

Rationale for Live Activity *

Select all that apply

Provides opportunity for real-time participant interaction

Increases opportunities for learning directly from expert presenters

Setting facilitates discussion of activity

Other

Rationale for Live Activity Other

Rationale for Enduring Activity *

Select all that apply

Allows participants to self-pace

Accessible at participant convenience

Other

Rationale for Enduring Activity Other

Target Audience *

Select all that apply. Must include at least one physician option to qualify for ACCME accreditation.

Target Audience Other

Desired Outcomes *

Change in competence, performance, or patient outcomes that should occur as the result of the activity.

Educational Need *

The cause or reason for the practice gap

Identified Practice Gap *

Difference between ACTUAL and IDEAL physician knowledge, competence, performance, and/or patient outcomes. Please include at least one professional citation if used to confirm practice gap.

Learning Objectives *

The take-home messages that bridge the gap between the identified Professional Practice Gap and the Desired Outcomes.

List of Verbs for Formulating Learning Objectives

Stay away from "learners will understand..." or participants will learn..."

Source: medicine.buffalo.edu/cme/planning_cme/policies/cme-activity-guidelines.html#title_1857167203

How will this enhance clinical skill? *

Developed in the context of which competencies? *

Select the box(es) to expand and select all that apply..

ACGME/ABMS

Institute of Medicine

Interprofessional Education Collaborative

ACGME/ABMS Competencies *

Select all that apply

Medical Knowledge

Professionalism

Systems-based practice

Patient Care and Procedural Skills

Practice-based Learning and Improvement

Interpersonal and Communication Skills

IOM Competencies *

Select all that apply

Provide patient-centered care

Apply quality improvement

Work on interdisciplinary teams

Utilize Informatics

Employ evidence-based practice

Interprofessional Education Collaborative *

Select all that apply

Values/Ethics for Interprofessional Practice

Interprofessional Communication

Roles/Responsibilities

Teams and Teamwork

Abstract

Abstract *

Please provide a brief, 3-5 sentence summary of your activity objectives.

Part Two: Post Test Comprehension Questions and Answers

Please make sure to indicate the correct answer if creating multiple choice questions.

Question 1 *

Answer 1 *

Question 2 *

Answer 2 *

Question 3

Answer 3

Question 4

Answer 4

Leave this field blank

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